Pilot Safety News
A Safety Journal for General Aviation
January, 2007 

by Max Trescott, Master CFI & FAA Aviation Safety Counselor
www.sjflight.com  (650)-224-7124

Index to Pilot Safety News
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I hope you enjoyed the holidays! There's remarkable flying weather around the country right now. Whether its global warming or not--take the opportunity to go out and practice some safe flying. 

Our first story is about a Cirrus crash at a ski resort in California two years ago in which the aircraft iced up soon after takeoff. Always, we're told not to speculate immediately after a crash as to the cause. In this case, the final report has at least one surprise. The real question is would you have taken off under the same circumstances, or continue the flight after you encountered icing?

Like the weather, Aeronautical Decision Making is something we talk a lot about, but there are relatively few models that give insight as to how to improve it. The Aviator's Model Code of Conduct is once such approach that we spotlight in this issue. Take a look at it and you might find a few new principles you can incorporate into your flying practices and decision making. 

In Buddy Can you Spare a Dime, we present many worthwhile charitable groups that would be happy to have you volunteer your flying skills on their behalf. If you're looking to add a new dimension to your flying, why not plan some flights this year that help others who are less fortunate? We were inspired to include this article after getting a great Christmas gift that let us choose a school at www.donorschoose.org to which to donate money for a project. Consider giving this gift to that hard to buy for person. 

Last month, we shared an interesting incident I witnessed at a local airport where a pilot told to "hold short" took off instead! We asked how you would have handled the incident, and you gave us your feedback. Would it surprise you that none of you recommended what the FAA ultimately did to this bozo?

If you plan to fly to the Castle airport in Atwater, CA in the future, you'll need to change your procedures for entering their airspace. Starting January 18, they will have a Class D and a control tower. 

Have fun and fly safely!
best regards,
Max Trescott, Master CFI

Final NTSB Report on Cirrus crash in icing
While not "known ice" should the pilot have known?

It’s hard to believe that it’s been almost two years since a Cirrus SR22 spiraled into Sugar Bush ski area, after being heavily loaded with ice on a flight from Reno , Nevada to the San Francisco Bay area. The crash was remarkable in that it crashed only 15 minutes after takeoff, and its parachute was shredded in the high speed descent, presumably because it was activated well above the maximum parachute deployment speed of 133 knots. Last month, the NTSB posted its final report on the crash, and it contains some critical lessons from which we can all learn.

The report highlights how early speculation about the causes of a crash can be misleading. While we all know that, it’s hard for pilots not to speculate. In this case, some of the early speculation was about how foolish the pilot was for taking off into known icing conditions. That’s a comforting assertion to make, since it helps us distance ourselves from the accident, and further reassures us that we would never make such an obvious mistake and hence are less vulnerable ourselves to having an accident. Lest you delude yourself into believing that accidents only happen to “bad pilots” consider this: How often have you heard someone say that an accident victim was a “good pilot?” The reality is that many accidents happen to good pilots who have a lapse in judgment. That may have been the case here.

 The final report summary reads:
Accident occurred Sunday, February 06, 2005 in Norden , CA
Probable Cause Approval Date: 12/28/2006
Aircraft: Cirrus Design Corp SR22 G2, registration: N286CD
Injuries: 1 Fatal.

The airplane, while operating under an instrument flight rules (IFR) flight plan, departed from controlled flight after encountering icing conditions, entered an uncontrolled descent, and collided with the ground. The airplane was equipped with an Ice Protection System that when activated supplied deicing fluid to the wings, tail, and propeller. The aircraft was not certified for flight into known icing and the Pilot Operating Handbook reads that, "Flight into known icing conditions is prohibited."

There are very few production single-engine aircraft certified for known icing. The Cirrus uses the TKS system to force glycol over the wings and elevator. A slinger tube deposits some glycol onto the prop, and residual glycol is “slung” from there onto the windshield. The system doesn’t meet the criteria for known icing, since there is no direct de-icing of the windshield. Also, with a full load of glycol, the system operate for only 30 minutes on the high setting, and 60 minutes on the normal setting. The system is most effective when it’s turned on before icing is actually encountered.

The Cirrus wing, is an ultra smooth, high performance airfoil, which contributes to the high performance of the airplane. Some people have suggested that it is less capable of carrying ice than some of the older, all metal wing designs used by other manufacturers. It would surprise me if that were true. Regardless, any accretion of ice in aircraft not certified for known icing should be treated as an emergency. The most prudent course of action is to make a 180° turn when icing is first encountered. It’s almost certain that doing so would have saved this pilot as we’ll show you in a moment.

The weather briefing
The pilot received a preflight weather briefing, which advised that there were no pilot weather reports (PIREP) for the intended route of flight, and that the freezing level in the Reno area was 6,000 feet with no precipitation. There were no valid SIGMET's or AIRMET's for icing conditions along the pilot's route. The pilot filed his IFR flight plan for 12,000 feet, but indicated he might request 14,000 feet once airborne.

This was a surprise to me and probably others who were familiar with this crash. I would have thought for sure that the pilot was briefed on icing conditions. I’ve read elsewhere that at least two pilots flew this route and didn’t report icing, however both left earlier during daylight hours, when it would have been much easier to fly around or under clouds to avoid picking up ice. By leaving at 6PM—after dark—our pilot added an additional risk factor, one which may have turned an otherwise ordinary flight into a deadly accident.

It’s virtually impossible to see clouds at night, unless there is a bright moon, or bright surface lights which illuminate the bases of the clouds. Anyone who’s flown over the accident area, at the north end of Lake Tahoe , near the Nevada/California border, knows that this mountainous resort area is sparsely populated with relatively few lights. This makes it virtually impossible for a pilot in this area to see and avoid clouds at night.

After takeoff, at 1807:46, the pilot contacted Oakland Air Route Traffic Control Center (ARTCC) and requested to climb to 16,000 feet to try to get above the clouds. At 1813:40, the pilot reported that he was still in the clouds and asked about going lower. At 1815:00, the pilot advised ARTCC that if he could go up another 200 to 300 feet, he could get above the clouds. ARTCC requested clarification if the pilot wanted to go up or down. The pilot responded that he would like to go up first to build up some airspeed. The pilot was cleared for a block altitude between 16,000 to 17,000 feet. 

What will you do when you encounter icing? Develop a plan now.
The other day, a pilot asked me if it’s always best to climb when encountering ice. In general, a 180° turn is the best response—unless you happen to be in a narrow mountain pass. If you start a standard rate turn immediately after you encounter ice, on average, you’ll exit the icing conditions in one minute, assuming the non-icing conditions you just left still exist behind you. Climbing, on the other hand, is fraught with problems.

In general, pundits will tell you that icing exists for only about 4,000 feet vertically, since once temperatures reach -20 to -30° C, the precipitation will be solid and won’t accrete onto an airplane. Even if that’s true 100% of the time (which I doubt!), that assumes that you aircraft is capable of climbing an additional 4,000 feet as it continue to accumulate ice during the climb. Let’s look at what’s working against you. All of these factors cause your climb rate to decrease, making it more difficult to climb 4,000 feet.

● As you climb, the engine develops less power, unless the airplane is turbocharged, and you’re below the airplane's “critical altitude” above which it can no longer maintain sea level air pressure to the engine.

● The propeller and wing both become less efficient as they climb into progressively thinner air. This is true for all aircraft.

● As you continue to fly through freezing conditions, additional ice may accumulate on the airframe. While the additional weight is a factor, the real killer—if we can use that phrase—is that the ice distorts the shape of the wing, and its ability to generate lift. As more ice accretes, it becomes more difficult for air to smoothly move over the wing. This disruption of laminar airflow leads to significant decreases in the lift generated, which further reduces an airplane’s ability to fly.

Another option is to descend, but this only works if the freezing level is above the MEA, allowing you to reach warmer temperatures where the ice will melt. This was not an option for our accident pilot, since the freezing level of 6,000 feet was below the 10-11,000 foot terrain over which he was flying.

At one point the accident pilot “advised ARTCC that if he could go up another 200 to 300 feet, he could get above the clouds.” This sounds like wishful thinking on his part. Sun and moon data for Truckee , CA for that date shows that the moon set at 2:43PM, so it was a dark night—more on that in a moment. Also, local sunset was at 5:28PM and civil twilight was at 5:56PM. By the time the pilot made this comment at 6:15PM, it would have been very dark, and virtually impossible to discern where the tops of the clouds were located.

The pilot also said that “he would like to go up first to build up some airspeed.” This suggests that the increasing load of ice was causing the aircraft to slow down and the pilot recognized he needed to speed up. However, “going up” would make him slower—only going down would increase his speed. In response, ATC assigned “a block altitude between 16,000 to 17,000 feet.” But at this point, the Cirrus SR22 was now within 2,000 feet of its maximum certificated altitude of 18,000 foot. Climb performance would be reduced in the best of circumstances, and was probably virtually non-existent with a growing load of ice.

About 2 minutes later, the pilot transmitted that he was "coming down" and that he was "icing up." The last transmission from the pilot was at 1817:42, again indicating that he was icing up and coming down. According to investigators from Ballistic Recovery Systems (BRS), following the examination of the ballistic parachute system, they determined the system was deployed outside of the operating envelope of the system, which is 133 knots indicated airspeed. An examination of the airplane wreckage did not reveal any evidence of preimpact mechanical failures or malfunctions.

Analysis of the actual weather conditions encountered revealed the likelihood that the pilot encountered severe icing related to super-cooled large water droplets as the aircraft achieved 16,000 feet and above. Review of the weather forecast products available at the time of the pilot's briefing disclosed that the AFSS briefing fully conformed to Federal Aviation Administration standards and adequately covered the observed and forecast weather conditions. Although post accident analysis of the weather conditions showed the clear likelihood of severe icing conditions, the algorithms used by the NWS Aviation Weather Center to predict icing conditions showed only a low probability of icing in the area, and, in the absence of PIREPs to the contrary, an icing forecast was not triggered. 

Chute happens--but a parachute won't save you all the time
Cirrus pioneered the use of parachutes in certificated single-engine aircraft, and the market has rewarded them for that innovation. Undoubtedly, countless purchase decisions have tipped in favor of Cirrus because of that seemingly fail-safe salvation. The general public seems to regard the parachute as a universal cure all. When interviewed by a TV reporter earlier this year regarding the Cory Lidle Cirrus crash into a building in New York City , I was asked “why the parachute didn’t save that plane.” Obviously, if the pilot didn’t have time to maneuver away from the building, the parachute would have done little more than slow the impact of the plane into the building, most likely with the same fatal result.

The question must be asked whether pilots flying under a parachute are more inclined to take risks that other pilots without a safety net—the parachute—are unwilling to take. If there’s a false belief that a parachute can safely extricate a pilot from every situation—including foolish ones of their own making—then to some extent the parachute may encourage risky behavior. If nothing else, this case highlights that one cannot wait until an accident sequence is fully developed before deploying the chute. Had the pilot deployed the chute earlier, when the plane was still under control, and not waited until it became uncontrollable under a heavy ice load, we’d probably be writing about this as another “save” by the parachute and not as an accident.

It’s certainly noteworthy that the pilot was not provided with an icing forecast, as noted in the final finding:
The National Transportation Safety Board determines the probable cause(s) of this accident as follows: the pilot's in-flight loss of control following an inadvertent encounter with unforecast severe icing conditions. A factor in the accident was the inaccurate icing forecast developed by the NWS Aviation Weather Center .

Was this accident avoidable?
So was our pilot a victim of fate? Were the circumstances beyond his control? Was this accident bound to happen, and our pilot just a hapless victim of imperfect weather forecasting? Perhaps, but we feel that there was plenty that should have raised red flags in this pilot’s mind both before he departed and after he was enroute.  

I love teaching FAA Wings Safety Seminars, because there’s always a good exchange and I learn as much from the attendees as they learn from me. An attendee at one such seminar told us that he has a rule of two. As I recall, he said he’d never allow two or more major risk factors. So for example, he’d fly in IMC, but not a night, or he’d fly in the mountains, but not in IMC and so on. In this case, our accident pilot had plenty of risk factors. He choose to launch on a dark night (no moon), in IMC, in the mountains, and in the winter when he’d be flying above the freezing level. Does this sound like an example of sound decision making?  

Why do we distinguish between night and dark night when there’s no moon? Because according to the NTSB, 90% of all night accidents occur in dark night when there’s no moon. Clearly, the lack of a moon makes it extremely difficult to see clouds, and dark night is particularly dangerous for non-instrument rated pilots. It also makes it difficult to find a suitable landing spot in case of an engine out emergency—a hazard for all pilots.

Instrument flying can bring additional risks, particularly in mountainous areas, where it forces IFR pilots to fly higher into clouds than VFR pilots, who can fly lower altitudes through mountain passes where they can remain below clouds. For example, this same exact flight would have posed no danger to the pilot if it were flown 75 miles away in California ’s central valley, where all terrain is below the 6,000 foot freezing level. Had the pilot encountered icing in clouds there, he could have descended below the freezing level—an option unavailable to him in IFR flight in the mountains. 

All of these factors should have raised red flags in our pilot's mind before he left the ground. If he wasn’t absolutely sure he could complete the trip safely, he should have considered alternatives. For example, Southwest airlines flies from Reno to the Bay area many times a day—he could have hopped a commercial flight or rented a car and come back for his plane on a nicer day. I’ve done it before on several occasions. Each time, I was extremely happy I made that decision, even though it was seemingly inconvenient.

For those who might say “yes, but” he received a poor weather briefing, there was nothing he could do, consider this. NEXRAD radar at the time showed precipitation from the northern edge of Lake Tahoe westward along the plane’s route of flight. So it should have been clear before he departed that he would enter precipitation above the freezing level and would almost certainly encounter icing. Furthermore, it’s almost certain that this aircraft was equipped with XM weather, and that the NEXRAD radar picture was available to the pilot in flight. Why would anyone knowingly continue flying through precipitation they could clearly see on radar, when they had no chance of descending below the freezing level?  It’s easy to say that hindsight is 20/20. Yet, in this case, it’s clear that the pertinent data was available to the pilot. Perhaps this is yet another example of a “good pilot” who had a brief lapse of judgment in the wrong place at the wrong time. If there’s a lesson, it’s that we should always scrutinize our decisions, always listen to the little voice in our head telling us something is not quite right, and always choose the most conservative option available to us—even it means finding another way to get to our destination.

The Aviator’s Model Code of Conduct 

Finally, a framework for “good decision making”

In the last issue, we talked about a crash of a plane that belonged to a club where I teach in which the pilot crashed in the mountains, at night, in bad weather, because he failed to, or was unable to, correctly follow a missed approached procedure. Miraculously, that pilot and his young son both survived with minor injuries.   

While poor decision making was possibly a factor in that accident, it begs the question of what models do we use for good decision making? It’s easy to point out poor decision making by other pilots, but that’s probably not sufficient to guarantee that we consistently make good decisions ourselves.

Let me commend to you for your consideration a relatively new model for good decision making—the Aviator’s Model Code of Conduct, which you’ll find at www.Secureav.com. The code was started about five years ago by a neighbor of mine after, as I understand, he made a bad flying decision. The result, which he thought would take him a few weeks to complete, has been a five-year odyssey that’s involved pilots from around the world in developing multiple codes of conduct, for different types of flight, in at least seven languages.

We quote now directly from the code:

The Aviators’ Model Code of Conduct (Code of Conduct) presents broad guidance and recommendations for General Aviation (GA) pilots to improve airmanship, flight safety, and to sustain and improve the GA community. The Code of Conduct presents a vision of excellence in GA aviation. Its principles both complement and supplement what is merely legal. The Code of Conduct is not a “standard” and is not intended to be implemented as such.”

A vision of excellence is a great place to start. Would you like your flying to be anything less than excellent? I’m sure your passengers wouldn’t! Would you like your flying to go beyond “what is merely legal?” There are many things that are legal, but not necessarily safe, so yes, all of us should aspire to flying practices which go beyond the minimum legal requirements for flight.

We’ll list the seven principles and then highlight a few of the many items listed under these principles. To read all of the recommended practices, go to http://www.secureav.com/AMCC-v1.1.htm.

“The Code of Conduct consists of the following seven sections (each containing principles and sample recommended practices).

The Principles:
I.        General Responsibilities of Aviators
II.       Passengers and People on the Surface
III.      Training and Proficiency
IV.      Security
V.       Environmental Issues
VI.      Use of Technology
VII.     Advancement and Promotion of General Aviation

You can click on any of the links above to read each section and sample recommended practices. For example, under General Responsibilities of Aviators, we find:

Pilots should:

a.    make safety their number one priority,

b.    seek excellence in airmanship,

c.    develop and exercise good judgment,

d.    recognize and manage risks effectively,

e.    adhere to prudent operating practices and personal operating parameters (e.g., minimums),

f.     aspire to professionalism,

g.    act with responsibility and courtesy, and

h.    adhere to applicable laws and regulations. “

Some sample recommended practices from this section include:

Recognize the increased risks associated with flying in inclement weather, at night, over water, and over rugged, mountainous or forested terrain. Take steps to manage those risks effectively and prudently without exceeding personal parameters.

Develop, use, periodically review and refine personal checklists and personal minimums for all phases of flight operations. Seek input and review of these materials by a certificated flight instructor.

Minimize turns and maneuvers below 500 feet AGL (except as required for landings and obstacle departure procedures).

The first practice speaks directly to the Cirrus accident we discussed earlier in this newsletter. The pilot failed to identify or utilize alternates to mitigate the risk inherent in a night, IMC flight in mountainous conditions with precipitation and below freezing temperatures. Personal minimums relate to decisions you make in the comfort of your home about what conditions in which you will and will not fly. To download a personal minimums checklist go to my personal website at http://www.sjflight.com/Safety.htm and search for P-8740-56 among the safety brochures. Flying below 500 AGL, except to land is risky. If you don’t believe so, start reading more accident reports at www.ntsb.gov!

II. Passengers and People on the Surface

  Pilots should:

a.    maintain passenger safety first and then reasonable passenger comfort,

b.    manage risks and avoid unnecessary risks to passengers and to people and property on the surface and in other aircraft,

c.       brief passengers on planned flight procedures and inform them of any significant or unusual risks associated with the flight,

d.       seek to prevent unsafe conduct by passengers, and

e.       avoid operations that may alarm or annoy passengers or people on the surface.

Some sample recommended practices from this section include:

·         Tactfully disclose risks to each passenger and accept a prospective passenger’s decision to refrain from participating.

·         Require that passengers wear seat belts and shoulder harnesses, and consider the use of headsets (or ear plugs) during flight operations.

·         Provide an instructive passenger briefing in advance of the anticipated flight.

III. Training and Proficiency

  Pilots should:

a.       participate in training to maintain and improve proficiency beyond minimum legal requirements,

b.       participate in flight safety education programs,

c.       act with vigilance and avoid complacency,

d.       train to recognize and deal effectively with emergencies, and

e.       accurately log hours flown and maneuvres practiced to satisfy training and currency requirements.

Some sample recommended practices from this section include:

·         Pursue a rigorous, life-long course of aviation study.

·         Follow and periodically review programs of study or series of training exercises to improve proficiency. Adhere to a training plan that will yield new ratings, certificates and endorsements — or at the very least, greater flight proficiency.

·         Participate in the FAA Pilot Proficiency Award Program ("Wings").

·         Study and develop a practical knowledge of aviation weather.

·      Each month, review reports of recent or nearby accidents or incidents, focusing on contributing factors.

·      Register with www.faasafety.gov for safety meeting announcements and safety literature.

All of these practices recognize that getting a Private Pilot’s license means—literally—that you have met the MINIMUM standards for flight proficiency, as outlined by the FAA’s Practical Test Standard. When pursuing something as complicated as flying, do you aspire to just meeting minimum standards? Hopefully, you recognize that a Private Pilot’s license is truly a small stepping stone, and that you continue to study aviation and safe practices for the rest of your life. Getting new ratings or participating in the FAA Wings program are great ways to do this. Learn more about the weather—it’s a factor in a large percentage of accidents (2/3rds of fatal accidents in the S.F. Bay area involve night or weather or both) and the more you learn about it, the safer you’ll be. Review accident reports both here and at www.ntsb.gov. Finally, attend seminars. You can sign-up to receive emails that notify you of semiars in your area—all of which qualify for the FAA Wings program—by going to www.faasafety.gov.

We’ve just scratched the surface of the Aviator’s Model Code of Conduct. To learn more, read the entire code at www.Secureav.com.  

Buddy Can you Spare a Dime?
Use your flying skills to help others!
One nice gift I received this Christmas was not a new GPS, a new airplane, or anything else that you might find in Sporty’s catalog. Instead, it was a gift certificate that let me give money to an educational charity of my choice.  I can’t think of anything more important to the future of our country than educating the next generation. Here in California , the dollars spent per student each year are ridiculously low, and the needs for educational dollars everywhere in the country are high. If you’d like to give a gift like this, go to http://www.donorschoose.org and buy some gift certificates.  

What’s this got to do with flying? It reminded me of the many ways that pilots can help charitable organization by using their flying skills. So if you’re looking for a way to make your flying a little more meaningful, look into some of these organization, and start volunteering to fly on their behalf. Not only will it make you feel good for helping others, in many cases you’ll be able to deduct your flying expenses related to these flights.

I spent many years flying with Los Medicos Voladores or “Flying Doctors”, and at various times was the organization’s President, Vice President and website creator. LMV, which is based largely in Northern California, flies doctors, dentists and other medical personnel in small planes to provide free medical services in underserved areas of Mexico . The organization met many of my interests, including flying to interesting new places, building flying hours at a lower cost, and making a connection with my father who was an M.D. There are many ways that you can help LMV and other organizations like it. For more information on LMV, go to www.flyingdocs.org.

Here’s information on other organizations where you can volunteer your flying skills. I’ve copied most of this directly from the LMV website page I created with this information many years ago (hard to believe I’ve been making webpages for over 11 years now!)

California Based Flying Doctors Groups

Like LMV, flies medical volunteers in small planes to provide medical services in Mexico . Has chapters in Tucson and Phoenix , AZ; Ensenada , Mexico ;  Oakdale, City of Industry, San Luis Obispo , Sonora , Tustin , Bonsall, San Diego and Dana Point, CA.  Most chapters serve clinics in Baja, though Arizona chapters generally concentrate on mainland Mexico . A number of volunteers often drive to the clinics in Mexico in vehicles loaded with supplies.

You can also write to: Flying Samaritans, P.O. Box 3568 , City of Industry , CA    91744 or call 800-755-9018.

Based in Santa Ana , CA , with a chapter in Fresno . For further information you may call Dr. Ray Hendrickson @ 949-833-0101 days or 949-854-8800 evenings, or e-mail RayEsqPhD@prodigy.net

Based in Santa Barbara , CA. Flies regular monthly missions to service clinic in Cadeje, located in central Baja.

Provides free medical, dental, opthamological, chiropractic, and other services to the residents and visitors to the Vizcaino area 50 miles south of Guerrero Negro on the first weekend of every EVEN calendar month. The group is based out of Norco , Ca. and aircraft meet to pick up pax at Riverside (RAL).  Contact: Michael N. Budincich, D.C. office: 626 792 3390  home: 626 355-3232  fax: 626 355-9512  in Pasadena .

Pilot Volunteer Organizations

Angel Flight West and Airlifeline are groups of several hundred pilots across the country who volunteer their time, airplanes, fuel and expertise to give free rides to medical patients who need transportation to hospitals and doctors offices.  The Air Care Alliance lists similar groups that provide free transportation to patients throughout the U.S.

Environmental conservation organization.  Pilots fly members of various organizations to photograph areas not easily visible from the ground.  Call coordinator at 415-561-6250.

Wings of Hope provides the knowledge, free manpower, and facilities to restore aircraft for use for humanitarian purposes around the world.

A nonprofit organization that serves our wounded warriors and their families by arranging and providing free transport through a national network of donors, volunteer aircraft and pilots to:

- Bring family members to the sides of wounded warriors.

- Provide veterans transport from their homes to medical centers for treatment.

- Take veterans back home after treatment, or during breaks in treatment—breaks they might otherwise spend alone.

- Provide related compassionate travel assistance.

"Hold Short" Confused with "Cleared for Takeoff"
Now you’ll know the rest of the story
Last month, we told how I was recently on final and cleared to land when a plane on the ground was told to hold short, but instead took off without a clearance. When questioned by the FAA, the pilot explained that he had headset trouble and thought that he had indeed been cleared to take off. The pilot had about 200 hours of time.

We asked for you comments on how you thought this story should end and offered the following choices:

A. If the pilot was contrite about the incident and safety wasn't comprised, that should be the end of it.
B. The FAA should require remedial training with a CFI for this pilot.
C. The FAA should take enforcement action. Suspending his license for a month or two makes sense.

You didn’t disappoint us. We had many responses, virtually all of which picked some flavor of B or C. We’ve reprinted many of your comments at the end of this newsletter. My favorite, from another Master CFI was: “I think the guy should fry.” I thought that was a little harsh. I don’t think he should fry—but perhaps at least be lightly grilled or sautéed.

Here are more details on what happened. The pilot was instructed to hold short, and instead pulled onto the runway and took off. Being number one on final I asked the tower “Was that a hold short?” and the controller replied, almost sadly “Yes, it was.” A moment later the controller called the aircraft and asked “Is there an instructor on board.” There was no response. The plane flew out of the area and returned a few hours later.

So which FAR’s were violated? Here are a few I can think of without doing any research:

● Failure to read back a hold short clearance
● Failure to comply with an ATC instruction (to hold short)
● Taking off without a clearance
● Failure to maintain radio communications while in Class D

Honestly, if I were a FAA inspector, I wouldn’t hesitate to add the following:

● Violation of 91.13 Careless or Reckless operation.

I had two long conversations with the tower manager at the airport where this occurred, because I felt the violations were serious. The tower manager told me that he’s spoken to the pilot, who he said was very apologetic. The pilot explained that he was having “a headset problem” and that he thought that he’d been cleared to takeoff. The tower manager also mentioned that there was a potential language issue with the pilot. He didn’t explain that comment further, but I take it to mean that English is not his native language and that perhaps he has some difficulty in understanding English.

The tower manager told me that “safety wasn’t compromised” which made the entire incident less severe in his mind. He based that conclusion on the fact that my plane didn’t have to go around, and because the pilot said that he looked at the final before taking the runway, saw our plane, and concluded that he had enough time to get onto the runway and takeoff before we landed.

Ultimately, the tower manager decided not to file a pilot deviation report, which essentially means that the matter is over and won’t be pursued any further. The tower manager acknowledged that this was a particularly bad deviation and that he did come close to filing a report. When I asked why he didn’t file one, the local tower manager told me that he’d be “filing 4 to 5 reports a week” if he filed a report for every pilot error.

One FSDO inspector told me that it was contrary to FAA policy to not file an incident report in this situation. However, I respect that anyone in authority should have latitude in how they implement policy, and I’m sure the tower manager decided this within the context of the many other issues with which he or she has to deal with on a daily basis. Still, let’s look at some of the issues and conclusions.  

How do you decide what course of action to take?
Everyone has probably had a headset or intercom or radio problem at one time, so I can understand why at first blush, someone might be sympathetic and accept that as an explanation. It’s certainly possible to confuse similar sounding words.  But, any “reasonable” pilot would take the most conservative interpretation, and if in doubt seek clarification. Surely our 200 hour pilot knew that he was told one of three things: Hold short, position and hold or cleared for takeoff. The most conservative interpretation would be to do nothing and seek clarification, but it would also be reasonable to pull up and hold short if you knew that one of those three instructions had been issued.  

Instead, this pilot took the least conservative interpretation. Although he admitted he was having trouble hearing, he took off, even though it’s reasonable that the instruction could have been to hold short (which it was) or position and hold. Now we’re looking at something much different than a “headset problem.” Instead, there’s clearly a severe judgment problem. If you think about the cardinal rules of flying, the most important is to always maintain sufficient airspeed, lest yee stall and smite the earth. After that, what rules are more important than staying off a runway unless instructed otherwise? Some rules should be more important than others and this one must be near the top of the list.  

Student pilots often confuse “hold short” with “position and hold.” No doubt the FAA should change one of these to eliminate the confusion over these two similar sounding instructions. A student pilot I was flying with yesterday suggested the FAA use “position and stop” rather than position and hold, and I agree that would reduce confusion.

Now, I can tell you’re getting ahead of me on this. What possible confusion is there between the words “hold short” and “cleared for takeoff?”  I don’t notice a single syllable or phoneme in common between these phrases. So there’s virtually no possibility for confusion. And even if they were similar, a “reasonable” pilot would always seek clarification before taking the runway. Case closed. In my mind, at a minimum, this pilot needed remedial training in aeronautical decision making.

Safety wasn't compromised--Should that matter when the violation is flagrant?
One reason the case wasn’t referred for any further action was because “safety wasn’t compromised.” I agree that it wasn’t. But what if the airplane on final had been a Cirrus SR20 with an 80 knot approach speed, which was forced to go around. In that case, by the FAA definition, safety would have been compromised. Instead, the plane on final was a Cessna 172 with an ATP rated pilot on board. The moment we saw the plane take the runway, we immediately slowed to minimum approach speed (about 60 knots), possibly preventing the need for any go-around.One should ask why our preventative actions lessen the severity of the violations committed. Furthermore, why does the occurrence of a go-around mean that “safety was compromised?”  I’ve never done a go-around in which I felt my safety was in any way compromised. By executing a go-around early and correctly, a pilot only increases their safety.

The reasoning given for not writing up this pilot don’t seem logical. Instead of helping a pilot who clearly needs some remedial training, he essentially got a pass. He probably has few new insights into the horrendous flaws in his decision making process, which means we as pilots are still at risk whenever this bozo flies. Great.

So where should the line be drawn? Anytime the police step up patrols based on complaints of speeding in a neighborhood, most of the new speed ticket are issued to—guess who—residents of that neighborhood. So no, I’m not calling for a rash of enforcement action, because I know that I too make mistakes and might be called onto the carpet to answer for a mistake. And in the same situation, I would be grateful for not having my case referred for enforcement action or remedial training. Though how bad could the latter be? Would it really be such bad punishment to be forced to fly with a CFI after such an incident?

But I’m preaching to the choir. After all, you’ve already shared your comments on what you feel should have happened, and NONE of you felt this pilot should have gotten a free pass from the FAA on this one. You can find these comments at the end of the newsletter. And hey, let’s be careful out there!  

Back to the future at Castle Airport
New Class D and control tower opening 

If you haven’t read the Federal Register recently (just kidding—does anyone read that?), you may have missed that Castle Airport in Atwater, CA, the home of the fourth longest runway on the West coast, is getting a control tower again. Of course, it used to have a control tower years ago when it was home to a SAC base and dozens of our nation’s B-52 bombers. The bombers are gone and Castle was relatively quiet for many years. However a large flight school moved there last year, increasing the number of operations, and there’s also a need to protect IFR operations into the airport. You can read the Federal Register announcement here.

So effective 9AM on January 18, 2007, you’ll want to plan to use the following frequencies:
Tower/CTAF...................................... 118.175
Ground................................................ 133.575
AWOS............................................... 124.475
Pilot Controlled Lighting....................... 123.000
Unicom/ Gemini Flight Support.............. 123.075

You can also attend a Wings seminar at Castle the following day, January 19, when they’ll explain all of the changes. There’s one odd note in the Federal Register, which reads “This action would establish Class D airspace extending upward from the surface to 2,500 feet Mean Sea Level (MSL) within a 4.5 nautical mile radius of the airport.” Of course a standard class D has a four mile radius. For some reason--perhaps the two mile long runways--this new Class D is larger than standard.  

There are all kinds of reasons to go to Castle. The best of course is to view the many historic military aircraft at Castle Air Museum . Their collection has some rare birds including the SR-71 Blackbird, the fastest flying aircraft in the world today, an F-4 Thunderbird, a RB-36 Peacemaker, a B-24 Liberator. If you’ve never seen a Peacemaker—one flew over Jimmy Stewart in the movie Strategic Air Command—it’s quite a sight with it’s six propeller engines behind the wind of this massive bomber in a pusher configuration. 

You may also want to hold your next business conference or fly-in at Castle. If you choose to stay over and be billeted, according to their website, “You will be staying in what was formerly known as the TLQ’s (Transient Living Quarters), where all rooms remain intact with Air Force furniture, the very same that was used when this was an active base.”

If you happen to live near the Castle airport, you should know that AOPA is still looking for someone to volunteer to be the liaison to that airport for their Airport Support Network, whose mission is to Promote, Protect, and Defend America 's Community Airports . Some of things that volunteer would do include:

Regardless of where you live in the U.S, if you’re interested in finding out if your local airport needs a volunteer, check the list of airports at AOPA Airport Support Network and consider volunteering for a needy airport in your area.

Upcoming Events

Feb 15-17   Women in Aviation Conference                                                         Orlando, FL

Feb 28        G1000 Presentation by Max to Watsonville Airman's Association         Watsonville, CA  

Another great issue - thanks!
As to your question....
 C. The FAA should take enforcement action. Suspending his license for a month or two makes sense. Headset trouble would prompt me to say "Huh.  I didn't really hear what they said.  I'll ask them to repeat it." Or maybe even "Huh.  Headset not working.  Maybe I'll get that fixed before I take this plane flying." At a minimum, he should have read back "Cleared for takeoff" at which time the tower would have corrected him.  Can't really think of a good excuse for this one...
Jon G.
Thanks  for the outstanding info in your safety news.  Great mix of articles condensed for easy digestion yet satisfies  like a full meal! I would vote for “B.”  With limited details,  it seems even with headset trouble the positive exchange of “cleared to take off”, and the read back was not 100%.  Therefore I was taught “do not cross the line” , heck,  even with a clearance from ATC, or God (viewed as one and the same to many of us low time pilots) Always look at final approach before entering the active. Treat it as if it were a non-towerd field and expect an old Steerman W/O radios  to come floating by.  One time at RHV I was cleared for 31R with a guy on short final (over the mall parking lot) I responded with “unable , landing traffic, 19W will hold short. We’re all human, so let’s look out for one another.
Gary V.

With the limited information, I vote for (c), and need convincing that (b) is appropriate. He recognized a "faulty headset" while on the ground, and launched anyway.  Given the number of studies that indicate significant accidents are a result of a chain of bad decisions, this qualifies bad-decision #1 (though one could only guess if there were others in the pre-flight). I've NEVER had a controller bark at me for clarifying clearance instructions before entering an active runway, and have been thanked numerous times for catching tongue-slipped instructions at multiple runways (eg, a Freudian slip of "right" when "left" was intended).  Taking a runway without being absolutely sure is bad decision #2. 

It also displays blatant disregard for others in the decision making process.  Regardless of Tower presence, it is the pilot's responsibility to ensure safety - and that includes checking the airspace before taking the runway (pattern/situation awareness), and a plane on final always gets my attention.  If the tower gave departure clearance, there would have been additional instructions related to the plane cleared to land, eg, "immediate departure" - again, something I'd want to hear clearly before taxiing in front of something.  

My feeling is that he was lucky the count didn't keep incrementing to something more severe. The scale-tipping element (for me) for action (c) is that these mistakes are all attitude related, not technical. And I don't want to see a proliferation of freeway (me-first) attitudes in the skyways.
Steve S.

Regarding your request for an answer for the pilot who took off, when he had the tower request HOLD SHORT, I say the correct answer is C. The FAA should suspend his license for a few months and also require 10 hours with a CFI.   Sorry… so many things wrong with this scenario… taking off with a bad radio at a tower… not sure of the clearance but assuming cleared for takeoff???  This type of mistake not only endangers this pilot, but all of the rest of us.
BTW, thanks for your ongoing work, newsletter, training, etc… you are great!!! And very useful to us pilots.
Phil C.
Depending on where you were on final, he could have created a safety problem. I have had planes given permission to take off 'without delay' and they drug their feet to the point that I had to make a go-around. I left it to the tower to point out their lack of co-operation. They were humble, apologized, and I let it go at that.    Not knowing more of the details on this gentleman, I'd pick "C". A reality check early on, might make him a better pilot.
Jack C.

Thanks for the wonderful newsletter Max.  In response to the article about "Hold short"...ok, here we go!  Unless this pilot is cavalier and shows a pattern of willful disregard of instructions, I think it was an honest mistake and punishing him will not make him a better pilot.  Perhaps some remedial training, but I think a good BFR would be sufficient.  Accidents happen, and this was an "accident" that resulted in no risk or damage to anyone.  

But the real reason I am writing is about the TFR in Stockton .  Rather than reminding everyone to call flight service before every flight, let's spend our time lobbying our legislators to do away with that silly practice.  It surely creates more confusion, risk and violations than the debatable benefit it provides.  Last I heard not a single legitimate risk had been avoided.  I think it is a safe bet that if you really wanted to harm the president, you wouldn't let a silly little TFR stand in your way.  All it really provides is a moving opportunity to experience a violation of your very own.  It hasn't happened yet, but I can just see one of those intercepter jets causing a collision or other problem.
Norman S.

thanks Max.  I really appreciated your newsletter, as usual.
Boy, that last question really makes you think. To me, the pilot's response is more indicative of the issue that needs to be addressed.... He explained he had headset trouble and thought he had been cleared for takeoff.  If someone thinks something... like I think I have enough fuel left... they might already be wrong.  So, it's better to take the safe choice... land early, or ask the controller to "Say again."   So, this is why I think the pilot should have confirmed it, *especially* if he was having headset trouble. So... I think the FAA should require more training (b).  Suspension might not address the root cause and the pilot might still end up being unsafe. Thanks again for your newsletter.
Jordan R.
Hold short vs cleared for takeoff? Not surprising at all! I'm doing a paper on runway incursions etc for the upcoming Aviation Psychology conference, reviewing 2,000 ASRS reports -- done half of 'em now -- and I've seen bunches of circumstances in which folks get one clearance and do instead what they expected / wanted / whatever. The most common confusion is receiving "hold short" and then doing "position and hold." It might be the pilots are asleep at the switch, but when you see so many of the same kind of errors, you wonder if it's a systemic problem. I've got some theories on why this might occur, but I'll hold off on those until the paper is all done.
Ed W.
it depends. if he should have visually been able to see you, and still pulled out, without looking, 709 ride! minimum   if you were still a ways out & no conflict, at least some review with an instructor. At 200 hours he hopefully still has a good mentor, if not, he needs one.
Paul S.
With regard to the pilot who disregarded the "hold short", my vote would be to have this person be required to take some remedial instruction with a CFI. If he was having trouble with his headset, he should not have entered an active runway for ANY reason. If airplanes are lined up behind and a turn around is not feasible, I would shut down the engine and push my airplane out of the way if necessary. As you have always recommended, before crossing the hold bars, we should read back any instruction of "cleared for takeoff" - including the runway number - to ensure no confusion by either a controller or the pilot. Also, any communication from a tower to "hold short" requires that this be repeated to the controller. This kind of error is inexcuseable due to the consequences of causing a serious accident with an aircraft on final (or still on the runway). Thus,  the very least penalty should be retraining in my humble opinion!
Thanks for helping keep us pilots thinking!
Ron C.

After a few practice approaches in my 172, my safety pilot buddy and I are cleared to land, and on 2 mile final for 28R Monterey when another aircraft (a Cirrus!) calls ready at 28R and is cleared for takeoff by the tower! While we gulp, arrest descent and get spring loaded for the sidestep go around and radio call, the Cirrus driver is doing his job right and calls the tower to report the aircraft on short final.

Of course, a flurry of cancelled and reconfirmed clearances and profuse apologies followed. ( Monterey is a small place, we all know each other!) As they say, "no harm - no foul", but let's all remember that the guy on the other end of the radio is human too. This means controllers also make mistakes, and all of us out there need to maintain awareness and back each other up for safety. (And instructors need to continue, as mine did, to teach the poor, nervous, timid students to "question authority" sometimes.) But most of all my buddy and I regret that we missed that golden moment we have all dreamed about. We should have said: "Advise when ready to copy a phone number." We'd have bought the guy a beer!
Keith S.

B. The FAA should require remedial training with a CFI for this pilot. Include training on reading back clearances.
Aaron L.
Regarding the unauthorized take-off, I'd go with option "B".  Why?  If he was having headset trouble he should've known what to do.  That is, either tell the tower you didn't copy them and ask for a read back or taxi back to the ramp and resolve the issue.  A suspension (if this is his first offense) seems harsh but remedial training, particularly in communication problems and their solutions, seems warranted.
Jay B.

Pilot Safety News
© 2007 by Max Trescott
Master CFI & FAA Aviation Safety Counselor
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